Viola B. Leal

Feasibility of a patient decision aid about lung cancer screening with low-dose computed tomography.

OBJECTIVE New clinical guidelines endorse the use of low-dose computed tomography (LDCT) for lung cancer screening among selected heavy smokers while recommending patients be counseled about the potential benefits and harms. We developed and field tested a brief, video-based patient decision aid about lung cancer screening. METHODS Smokers in a cancer center tobacco treatment program aged 45 to 75 years viewed the video online between November 2011 and September 2012. Acceptability, knowledge, and clarity of values related to the decision were assessed. RESULTS Fifty-two patients completed the study (mean age=58.5 years; mean duration smoking=34.8 years). Acceptability of the aid was high. Most patients (78.8%) indicated greater interest in screening after viewing the aid. Knowledge about lung cancer screening increased significantly as a result of viewing the aid (25.5% of questions answered correctly before the aid, and 74.8% after; P<.01) although understanding of screening eligibility remained poor. Patients reported being clear about which benefits and harms of screening mattered most to them (94.1% and 86.5%, respectively). CONCLUSIONS Patients have high information needs related to lung cancer screening. A video-based decision aid may be helpful in promoting informed decision-making, but its impact on lung cancer screening decisions needs to be explored.

Patient Decision Aids for Colorectal Cancer Screening: A Systematic Review and Meta-analysis

CONTEXT Decision aids prepare patients to make decisions about healthcare options consistent with their preferences. Helping patients choose among available options for colorectal cancer screening is important because rates are lower than screening for other cancers. This systematic review describes studies evaluating patient decision aids for colorectal cancer screening in average-risk adults and their impact on knowledge, screening intentions, and uptake. EVIDENCE ACQUISITION Sources included Ovid MEDLINE, Elsevier EMBASE, EBSCO CINAHL Plus, Ovid PsycINFO through July 21, 2015, pertinent reference lists, and Cochrane review of patient decisions aids. Reviewers independently selected studies that quantitatively evaluated a decision aid compared to one or more conditions or within a pre-post evaluation. Using a standardized form, reviewers independently extracted study characteristics, interventions, comparators, and outcomes. Analysis was conducted in August 2015. EVIDENCE SYNTHESIS Twenty-three articles representing 21 trials including 11,900 subjects were eligible. Patients exposed to a decision aid showed greater knowledge than those exposed to a control condition (mean difference=18.3 of 100; 95% CI=15.5, 21.1), were more likely to be interested in screening (pooled relative risk=1.5; 95% CI=1.2, 2.0), and more likely to be screened (pooled relative risk=1.3; 95% CI=1.1, 1.4). Decision aid patients had greater knowledge than patients receiving general colorectal cancer screening information (pooled mean difference=19.3 of 100; 95% CI=14.7, 23.8); however, there were no significant differences in screening interest or behavior. CONCLUSIONS Decision aids improve knowledge and interest in screening, and lead to increased screening over no information, but their impact on screening is similar to general colorectal cancer screening information.

Using a Patient Decision Aid Video to Assess Current and Former Smokers’ Values About the Harms and Benefits of Lung Cancer Screening With Low-Dose Computed Tomography

Background. Recent policy changes require discussing the potential benefits and harms of lung cancer screening with low-dose computed tomography. This study explored how current and former smokers value potential benefits and harms after watching a patient decision aid, and their screening intentions. Methods. Current or former smokers (quit within 15 years) with no history of lung cancer watched the decision aid and responded to items assessing the value of potential benefits and harms in their decision making, and their screening intentions. Results. After viewing the decision aid, participants (n = 30; mean age 61.5 years, mean 30.4 pack-year history) were well-informed (mean 80.5% correct responses) and rated anticipated regret and finding cancer early as highly important in their decision (medians >9 out of 10), along with moderate but variable concerns about false positives, overdiagnosis, and radiation exposure (medians 7.0, 6.0, and 5.0, respectively). Most participants (90.0% to 96.7%) felt clear about how they personally valued the potential benefits and harms and prepared for decision making (mean 86.7 out of 100, SD = 21.3). After viewing the decision aid, most participants (90%) intended to discuss screening with their doctor. Limitations. The study is limited to current and former smokers enrolled in a tobacco treatment program, and it may not generalize to other patient populations. Conclusions. The majority of current and former smokers were strongly concerned about anticipated regret and finding cancer early, while concerns about radiation exposure, false positives, and overdiagnosis were variable. After viewing the decision aid, current and former smokers reported strong preparedness and intentions to talk with their doctor about lung cancer screening with low-dose computed tomography.

From guideline to practice: New shared decision-making tools for colorectal cancer screening from the American Cancer Society

The goal of the American Cancer Society (ACS) 2018 guideline update for colorectal cancer (CRC) screening is to reduce the incidence of and deaths from CRC for average-risk adults aged 45 years and older through the use of screening tests that are selected to align with a patient’s preferences and test availability. Beginning screening at age 45 years is a qualified recommendation, and regular screening of adults aged 50 years and older is a strong recommendation. The basis for the grading of these recommendations is described in the guideline update. For adults in good health with at least a 10-year life expectancy, screening should continue to age 75 years, whereas the decision to screen individuals ages 76 through 85 years should be individualized based on patient preferences, life expectancy, health status, and prior screening history (qualified recommendation). Clinicians should discourage individuals older than 85 years from continuing screening (qualified recommendation). The updated guideline includes details about the process for developing and rating the recommendations. In the updated guideline, the ACS Guideline Development Group placed greater emphasis on the importance of patient preferences and choice in selecting a screening test, with the goal of increasing CRC screening uptake and adherence. Six screening options are included in the new guideline, including 3 stool-based tests (fecal immunochemical test [FIT]; high-sensitivity guaiac-based fecal occult blood test [HSgFOBT]; and multitarget stool DNA test [mt-sDNA]) and 3 structural (visual) examinations (colonoscopy, computed tomography colonography [CTC], and flexible sigmoidoscopy [FS]). Each option is associated with unique operational and performance attributes as well as demands on patients, and there is an extensive literature demonstrating variability in how patients value the attributes of CRC screening options. These attributes, which include the frequency of testing, test procedures, and required preparation, alone or in combination, can impact a patient’s preference for CRC screening tests. Provider recommendations also strongly influence the uptake of screening and choice of test. Decision making about CRC screening therefore involves the patient weighing the importance of the test attributes when making a decision with a health care provider about which test is right for them. In the absence of the provider’s assessment of patient preferences, screening may not take place if the test offered is judged by the patient to be undesirable. There is evidence that screening intentions are higher among patients who are offered an option that is consonant with their preferences. The updated guideline emphasizes the importance of communication about CRC screening between health care providers and patients to improve CRC screening utilization. Shared decision making is a collaborative process that allows patients and their health care providers to make decisions together, accounting for the best scientific evidence available as well as the values and preferences of the patient. With the release of its updated CRC screening guideline, the ACS has developed decision support tools to engage patients and health care providers in making shared decisions about screening (cancer.org/health-care-professionals/ colon-md.html). Here, we introduce these new tools for supporting shared decision Professor, Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX; Program Manager, Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX; Project Manager, Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX; Associate Professor of Medicine, Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA; Vice President, Cancer Control Interventions, Prevention, and Early Detection, American Cancer Society, Atlanta, GA; Chief Cancer Control Officer, American Cancer Society, Atlanta, GA; Professor, Department of Family and Community Medicine, Thomas Jefferson University, Philadelphia, PA; Vice President, Cancer Screening, Cancer Control Department, American Cancer Society, Atlanta, GA.

Pathways: patient-centred decision counselling for women at risk of cancer-related infertility: a protocol for a comparative effectiveness cluster randomised trial

Introduction National guidelines recommend that all reproductive-age women with cancer be informed of their fertility risks and offered referral to fertility specialists to discuss fertility preservation options. However, reports indicate that only 5% of patients have consultations, and rates of long-term infertility-related distress remain high. Previous studies report several barriers to fertility preservation; however, initial success has been reported using provider education, patient decision aids and navigation support. This protocol will test effects of a multicomponent intervention compared with usual care on women’s fertility preservation knowledge and decision-making outcomes. Methods and analysis This cluster-randomised trial will compare the multicomponent intervention (provider education, patient decision aid and navigation support) with usual care (consultation and referral, if requested). One hundred newly diagnosed English-speaking women of reproductive age who are at risk of cancer-related infertility will be recruited from four regional oncology clinics. The Pathways patient decision aid website provides (1) up-to-date evidence and descriptions of fertility preservation and other family-building options, tailored to cancer type; (2) structured guidance to support personalising the information and informed decision-making; and (3) a printable summary to help women prepare for discussions with their oncologist and/or fertility specialist. Four sites will be randomly assigned to intervention or control groups. Participants will be recruited after their oncology consultation and asked to complete online questionnaires at baseline, 1 week and 2 months to assess their demographics, fertility preservation knowledge, and decision-making process and quality. The primary outcome (decisional conflict) will be tested using Fisher’s exact test. Secondary outcomes will be assessed using generalised linear mixed models, and sensitivity analyses will be conducted, as appropriate. Ethics and dissemination The University of Texas MD Anderson Cancer Center provided approval and ongoing review of this protocol. Results will be presented at relevant scientific meetings and submitted for publication in a peer-reviewed journal. Trial registration number NCT03141437; Pre-results.

Development and pilot testing of an online case-based approach to shared decision making skills training for clinicians

BackgroundAlthough research suggests that patients prefer a shared decision making (SDM) experience when making healthcare decisions, clinicians do not routinely implement SDM into their practice and training programs are needed. Using a novel case-based strategy, we developed and pilot tested an online educational program to promote shared decision making (SDM) by primary care clinicians.MethodsA three-phased approach was used: 1) development of a conceptual model of the SDM process; 2) development of an online teaching case utilizing the Design A Case (DAC) authoring template, a well-tested process used to create peer-reviewed web-based clinical cases across all levels of healthcare training; and 3) pilot testing of the case. Participants were clinician members affiliated with several primary care research networks across the United States who answered an invitation email. The case used prostate cancer screening as the clinical context and was delivered online. Post-intervention ratings of clinicians’ general knowledge of SDM, knowledge of specific SDM steps, confidence in and intention to perform SDM steps were also collected online.ResultsSeventy-nine clinicians initially volunteered to participate in the study, of which 49 completed the case and provided evaluations. Forty-three clinicians (87.8%) reported the case met all the learning objectives, and 47 (95.9%) indicated the case was relevant for other equipoise decisions. Thirty-one clinicians (63.3%) accessed supplementary information via links provided in the case. After viewing the case, knowledge of SDM was high (over 90% correctly identified the steps in a SDM process). Determining a patient’s preferred role in making the decision (62.5% very confident) and exploring a patient’s values (65.3% very confident) about the decisions were areas where clinician confidence was lowest. More than 70% of the clinicians intended to perform SDM in the future.ConclusionsA comprehensive model of the SDM process was used to design a case-based approach to teaching SDM skills to primary care clinicians. The case was favorably rated in this pilot study. Clinician skills training for helping patients clarify their values and for assessing patients’ desire for involvement in decision making remain significant challenges and should be a focus of future comparative studies.